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Member in-network, out-of-pocket accumulation required under Affordable Care Act

For plan years that begin on or after January 1, 2015, AmeriHealth New Jersey is required by the Affordable Care Act (ACA) to calculate our members' in-network out-of-pocket (OOP) cost-sharing expenses. This means we need to ensure any in-network deductibles, copayments, and coinsurance for Essential Health Benefits such as medical, prescription drug, vision riders, and behavioral health services are included in the in-network OOP maximum (including benefits covered by third-party vendors). In addition, the in-network OOP maximum cannot exceed the following requirements as defined by the ACA:

•    In-network OOP maximum for non HSA-qualified HDHP plans: For new and renewing benefits on and after January 1, 2015, the annual in-network OOP maximum cannot exceed $6,600 for single and $13,200 for family coverage.
•    In-network OOP maximum for HSA-qualified HDHP plans: For new and renewing benefits on and after January 1, 2015, the annual in-network OOP maximum cannot exceed $6,450 for single and $12,900 for family coverage.

These plans have different limits which are indexed annually based on IRS guidelines. MORE

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